During the course of a patient's stay in an inpatient or acute care facility, the patient will be seen by a variety of health care providers as they review the patient's status, recommend treatments and protocols, provide care, order tests, etc. Providers must record all of their activities and decisions for the patient, and efficient communication of this information between all of a patient's caregivers is key to the problem of providing a patient with the best possible care.
Existing approaches to this problem typically center on some kind of shared patient record. A shared paper chart kept in or near the patient's room represents perhaps the most common but also the least effective approach. A shared paper chart offers very limited security and virtually no simultaneous access for either viewing or editing the patient's hospital record. What's more, as information is eventually added to the patient's record from a large number of caregivers, it becomes increasingly difficult and time consuming to identify and review appropriate information for a particular situation.
A computer-based approach can solve some of these problems by providing a central repository for storing and accessing clinical documentation for a patient, and in recent years many computer-based clinical documentation systems have been conceived and implemented for both ambulatory and acute care settings. However, these systems typically demonstrate weaknesses and problems that result in a failure to ensure efficient communication between a patient's acute caregivers. Problems with these systems include a failure to address one or more of the following needs:                providing a single point of access to the information recorded by all of the patient's caregivers during an acute care episode;        providing simultaneous access to a patient's chart for both viewing and editing from different locations while maintaining data integrity;        providing role-based security to limit each caregiver's viewing and editing access to a patient's chart;        providing user-linked time-stamps for both data entry and review that a) make it easy to present a longitudinal view of the patient record, b) provide a means for a user to quickly see information that's been added to the patient's record since the user's last review, and c) providing for note cosign by one or more caregivers;        providing for storing and sorting patient notes according to caregiver's roles, service areas and etc.;        providing easy to use filter and search tools that allow a caregiver to quickly identify and review clinically appropriate information for a given situation;        providing for entering data other than entirely manual keyboard entry, for example automated text-entry options, dictation, voice recognition, etc.;        providing for incorporating available information relevant to a patient's acute care episode, for example emergency room (ER) notes, hospital discharge summaries etc.        
Thus, there is a need for a clinical documentation system that addresses these needs within the healthcare enterprise.